Practice Management Alert

Question: What are any best practices for minimizing denials from Tricare?

North Carolina Subscriber

Answer: Look to these three tips: File in a timely manner, understand coverage options for services and devices, and check whether Tricare is a patient’s secondary payer.

Your practice most likely files claims on the date of service, but practices often find unfiled claims during internal audits or record reviews, and you may want to send in claims later than usual. In the case of Tricare, you only have a year from the date of service (or a year from the discharge date for inpatients) — after that, the claim will be denied. This is similar to how Medicare provides you with just one year to submit claims following the date of service.

“Claims must be filed within one year of the date of service or within one year of the date of an inpatient discharge or three years if overseas, but you are encouraged to send your claim form to Tricare as soon as possible after you receive care,” the Tricare website notes.

As with other payers, you can file appeals to Tricare when warranted, but you must follow the instructions that come with your claim denials to successfully appeal a Tricare claim.

Tricare does include coverage for services like ear tube insertions, tonsillectomies, and audiology services, as well as hearing aids, but as with any insurer, you must follow instructions to the letter if you want your claim processed successfully.

For instance, Tricare will cover hearing aids for active-duty service members and their families, but not for retired service members or their families. Even for those on active duty, specific criteria must be met, depending on the patient’s age:

• Adults who have a hearing threshold of at least 40 dB HL in one or both ears when tested at 500; 1,000; 1,500; 2,000; 3,000; or 4,000Hz — or hearing threshold of at least 26 dB HL in one or both ears at any three or more of those frequencies, or speech recognition score less than 94 percent
• Children with hearing threshold levels of at least 26dB HL in one or both ears when tested at 500; 1,000; 2,000; 3,000; or 4,000Hz

Tricare is specific about which services are payable and which aren’t, and you should always contact the phone number on your patient’s insurance card if you’re ever unsure of whether a service is covered. Certain services, such as vestibular rehabilitation and acupuncture, for instance, are excluded from coverage.

If a particular patient has Tricare as well as insurance through another source, you should almost always consider the other insurance primary. “By law, Tricare pays after all other health insurance except for Medicaid, Tricare supplements, state victims of crime compensation programs or other federal government programs (i.e., Indian Health Services),” Tricare says on its website.

Keep in mind that the exception above applies to Medicaid, but not Medicare. Therefore, if you see a disabled patient who is on Medicare via their disability, but also has Tricare, you should submit the claim to Medicare first, and then the balance bill can go to Tricare. If, however, the patient has both Medicaid and Tricare, bill Tricare first, and then file with Medicaid.

For more on this issue, see www.tricare.mil/Plans/OHI.aspx.